Introduction

Abdominal thrusts or the Heimlich maneuver is a first aid procedure used to treat upper airway obstruction caused by a foreign body. This skill is commonly taught during basic life support (BLS) and advanced cardiac life support (ACLS) classes but is never given the necessary attention as chest compressions and rescue breaths do. The abdominal thrust maneuver can be performed in both children and adults via different techniques.[1]

In the 1960s, choking on food, toys, and other objects was the sixth leading cause of accidental death in the United States. Slapping individuals on the back was the main response and was frequently found to be ineffective, at times even lodging the object further down.[2]

The Heimlich maneuver was initially introduced in 1974 by Dr. Henry Heimlich after proving his theory that the reserve of air in the lung could serve to dislodge objects from the esophagus by quick upwards thrust under the ribcage.[3][4] The medical community of the time did not embrace the maneuver right away. The American Red Cross (ARC) and American Heart Association (AHA) continued to promoted backslaps for 10 years after the Heimlich maneuver was introduced.[5][6]

Today, the Heimlich maneuver is accepted and taught during BLS and ACLS for conscious adults, but backslaps are still recommended for infants and chest compressions are recommended for unconscious patients. Furthermore, different techniques of the maneuver have been developed with conflicting effectiveness results.[7]

Anatomy

The anatomy associated with the Heimlich maneuver is mainly focused on expelling a foreign body by standing on the rear of the patient, placing arms around and delivering a sharp inward and upward thrust to the abdomen below the rib cage.[8] Foreign objects associated with choking are usually stuck above the cricoid cartilage in the supra-laryngeal area. As for the maneuver itself, the thrusts must be executed over the epigastric region just below the ribcage and directed upwards towards the head of the patient.[9] If the patient is pregnant, the thrust maneuver can be performed over the sternum.

Physiologically, the abdominal thrust maneuver is effective due to increasing intrathoracic pressure affecting the lung/airway, stomach, and esophagus produced by diaphragmatic thrusts.[10]

Indications

The only accepted indication for the abdominal thrust maneuver is that of the conscious choking adult from a lodged supra-laryngeal foreign body. The universal choking sign is regarded as the main indication for the Heimlich maneuver. This sign consists of the inability to speak, breathe, or cough while holding both hands up to one's own throat.[11]

Although initially reported to help with asthma and drowning patients, the Heimlich maneuver has not been proven to help with these diagnoses.[12] Another case study presented the inadequate purging use of the Heimlich maneuver in teenagers with eating disorders.[9]

Contraindications

Although there are no absolute contraindications, the abdominal thrust maneuver is not recommended by the AHA for infants or unconscious patients. In addition, pregnant subjects should be managed with sternal compressions, as opposed to abdominal.[13]

Personnel

The importance and utility of the Heimlich maneuver lie in the fact that it does not require expertise but simple training of the public.[14] When Dr. Heimlich introduced the abdominal thrust maneuver in 1974 through live television, it was not until real-life anecdotes from viewers came along that it was accepted by the medical community.[3] Today, it is commonly taught in BLS classes and does not require equipment.

Preparation

Cases of choking happen in mere seconds and unexpectedly, making preparation nearly impossible. As mentioned above, the Heimlich maneuver is taught during BLS for the conscious choking adult.

Technique

The commonly known abdominal thrust maneuver, known as the Heimlich maneuver, is performed by a bystander on a person who appears to be choking. The bystander stands behind the subject and wraps his/her arms around the upper abdominal region, about two inches above the belly button. Making a fist with one hand and wrapping the other hand tightly over the fist and delivering 5 sharp midline thrusts inward and upward.[15] Recently, other techniques such as the circumferential (horizontal) abdominal thrust, chair thrust, and auto up-thrust have been studied comparing the gastric and esophageal pressures generated with each, finding that chair thrusts might be more effective in these parameters.[7]

Other studies report higher effectiveness of lateral thoracic and abdominal thrusts in the generation of airway pressure as studied in pigs.[16][17] A manikin study in 2017 reported improved effectiveness of the Heimlich maneuver while on a supine or prone position for adults and prone position for children.[18] Another study reports using a modified table Heimlich maneuver with success in four unconscious patients.[19]

Complications

Ever since the introduction of the Heimlich maneuver, cases of harm inflicted by the forceful displacement of the diaphragm and sudden increase in intrathoracic pressure have driven numerous studies and reviews. Although this maneuver is considered life-saving and generally safe to perform, serious intra-abdominal harm can ensue from incorrect technique and unusually vigorous application.[20] One manikin study mentioned above also concluded that the risk of serious harm ensues if the foreign body is not relieved after the first set of thrusts.[18] The most commonly reported complications are rib fractures and gastric or esophageal perforations. Although other rare traumatic injuries such as splenic rupture, pneumomediastinum, aortic valve cusp rupture, diaphragmatic herniation, jejunum perforation, hepatic rupture, and mesenteric laceration have been described[21][22][23]

Clinical Significance

The abdominal thrust maneuver impact on basic life support, both on the medical and public sector, cannot be quantified. Despite the rare instances of intraabdominal complications, the Heimlich maneuver is considered a quick and inexpensive technique that does not require medical knowledge or expertise to perform.[3] With the addition of the maneuver by the AHA into the BLS program, medical performance and effectiveness of cardiopulmonary resuscitation improved.[24] A 2015 study evidenced the improved outcomes of patients treated in the field by bystanders in comparison with those treated initially in the hospital.[25]

Enhancing Healthcare Team Outcomes

The Heimlich maneuver exemplifies what can be achieved by involving the general population in community healthcare. BLS training is progressively required for an increasing part of the community, even including high-school students.[26] (Level III) Ultimately, the overall improvement in patient outcomes has been found to rely heavily on bystander cardiopulmonary resuscitation and basic life support.[27] (Level I)

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A 6-month-old female is witnessed putting a big plastic toy in her mouth and proceed to choke. The child is responsive but in distress and the mother is screaming for help. What is the correct procedure to perform next?

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Rottenberg EM, Could there ever be evidence to support using lateral chest thrusts in humans with the victim lying on their side to clear upper-airway obstruction? Resuscitation. 2013 Jun [PubMed]

Blain H,Bonnafous M,Grovalet N,Jonquet O,David M, The table maneuver: a procedure used with success in four cases of unconscious choking older subjects. The American journal of medicine. 2010 Dec [PubMed]

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